Scleroderma-like Reaction Restricted to the Red Parts of a Tattoo

Abstract

The introduction of pigments or dyes during tattooing may trigger various histological types of hypersensitivity reaction, mainly lichenoid, granulomatous, sarcoidosis-like, pseudolymphomatous and eczematous (1). The time of appearance of these reactions is highly variable, from immediately after tattooing to 45 years later (2). We report here an unusual case of dermal sclerosis restricted to the red part of tattoos. Such “scleroderma-like” reactions have been reported on very few occasions (3, 4). CASE REPORTAn otherwise healthy 47-year-old woman presented for an inflammatory infiltration of an ankle tattoo, which had become symptomatic almost immediately after tattooing. Eighteen months earlier, a yellow, orange, red, white and black “sacred heart” had been tattooed on her ankle in a professional tattoo parlour (Fig. 1A). Within the first week, she noticed unusual swelling and delayed healing. Pruritus had been intense, with a severe impact on daily living and sleep for the past 18 months. This episode was the first she had reported after tattooing, as she had been tattooed three times pre-viously without complication. However, a concomitant itchy reaction had also developed at this time on the red part of another tattoo located in the lumbar area, which had been drawn by the same artist with the same red ink 6 months before the “sacred heart”. Both reactions had remained stable without improvement. She refused to apply any corticosteroid ointment during this time. Examination of the 18-month-old tattoo showed an inflamed, squamous and indurated infiltration confined to the red parts. Several exulcerations were noted over the red area (Fig. 1B). Physical examination was other-wise normal, with no sign of systemic scleroderma. The clinical features were suggestive of a red tattoo pigment hypersensitivity reaction. Histological examination of a 4-mm punch biopsy of the red tattoo revealed a lichenified epidermis with com-pact hyperkeratosis, hypergranulosis and acanthosis. An inflammatory sclerosis was located in the superficial and mid-dermis with thickened and homogenized collagen bundles, lymphocytes and macrophages. Exogenous red tattoo pigments were localized around mid-dermal vessels free in the dermis or in macrophages. Focal lichenoid reaction was observed (Fig. 2). The features were not indicative of localized scleroderma. A diagno-sis of dermal sclerosis related to a chronic inflammatory reaction to the red pigment was suspected. No test could be performed on the culprit red ink as the manufacturer did not reply to our request for a sample or information on its composition. Betamethasone dipropionate 0.05% ointment was applied daily for a month and then tapered slowly over 3 months. Pruritus resolved within a week and lesions improved within the first 2 months. After 3 months, no inflammation was noted. We suggested that the patient avoid further tattooing with any type of red ink in the absence of identified components. She had two new tattoos done with various colours (yellow, green, blue, orange, pink, violet, brown and black) without complication. However, one of them was a pink cat with red ink from a different manufacturer applied for the nose. Pruritus occurred on that very location after tattooing, but no recall reaction occurred elsewhere. She and her tattooist have decided to stop using red ink.DISCUSSIONWe report here an unusual and severe “scleroderma-like” reaction after tattooing, which was restricted to the red parts of a tattoo. Symptoms of hypersensitivity reaction to tattoo pigments are often non-specific, including discomfort, swelling, papules or nodules and pruritus (5). Clinical induration is not an uncom-mon manifestation of tattoo reactions (5), but the